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PM R. 2015 Feb;7(2):222-5. doi: 10.1016/j.pmrj.2014.09.017. Epub 2014 Dec 9.

Participation in ball sports may represent a prehabilitation strategy to prevent future stress fractures and promote bone health in young athletes.

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Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, CA∗
Division of Epidemiology, Department of Health Research and Policy, Stanford University, Stanford, CA(†).
Duke School of Medicine, Duke University, Durham, NC(‡).
Hadassah University Hospital, Hebrew University Medical School, Jerusalem, Israel(§).
Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, CA(¶). Electronic address:


Sports participation has many benefits for the young athlete, including improved bone health. However, a subset of athletes may attain suboptimal bone health and be at increased risk for stress fractures. This risk is greater for female than for male athletes. In healthy children, high-impact physical activity has been shown to improve bone health during growth and development. We offer our perspective on the importance of promoting high-impact, multidirectional loading activities, including ball sports, as a method of enhancing bone quality and fracture prevention based on collective research. Ball sports have been associated with greater bone mineral density and enhanced bone geometric properties compared with participation in repetitive, low-impact sports such as distance running or nonimpact sports such as swimming. Runners and infantry who participated in ball sports during childhood were at decreased risk of future stress fractures. Gender-specific differences, including the coexistence of female athlete triad, may negate the benefits of previous ball sports on fracture prevention. Ball sports involve multidirectional loading with high ground reaction forces that may result in stiffer and more fracture-resistant bones. Encouraging young athletes to participate in ball sports may optimize bone health in the setting of adequate nutrition and in female athletes, eumenorrhea. Future research to determine timing, frequency, and type of loading activity could result in a primary prevention program for stress fracture injuries and improved life-long bone health.

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